Severe bronchospasm using Diprivan® in a patient allergic to peanut and birch

Diprivan^® is composed of propofol, refined soybean oil and purified egg phosphatide. One must eliminate any allergy to one of its components before use. We report the story of a child who underwent nevus surgery under general anesthesia which was associated with an hypersensitivity reaction. In fact, this child had asthma and allergy to peanuts, raising the problem of cross allergy between birch, peanut, soy and Diprivan^®.     

Identification and classification in le fort type fractures by using 2D and 3D computed tomography

In1901,basedontheexperimentationwithbrittlewandstrokingcadaverskulls,LeFortfirstlyclassifiesmaxillofacialfracturesintothreetypes.Atpresent,theclassificationisstillusedtodistinguish clinicalmaxillofacialfracturesintheworld.1,2The diagnosisofLeForttypefracturereliesonthephysical andradiologicalexamination,butthephysicalfindings maynotalwaysbepresent.35Conventionalradiographs areroutinelyusedforLeForttypefracture,however,theoverlapofstructuremayimpairproper interpretationofimages.35Routinecomp…     

Specimen diameter and “side artifacts” in cancellous bone evaluated using end-constrained elastic tension

In cancellous bone testing of cored samples, side artifacts are the underestimation of the true (i.e. in situ) mechanical properties due to the severing of the trabecular network during specimen preparation. Although other researchers have suggested correction factors derived from finite element method (FEM) models, it is proposed that side effects can be minimized by increasing the specimen diameter. Six different diameter specimens (3.1–10.6 mm), from two different anatomic sites (bovine femoral condyle and bovine lumbar vertebrae), were mechanically tested in elastic tension using an epoxy endcap protocol to eliminate end artifacts. Elastic modulus was found to be significantly affected by diameter in both sites. For example, the 5.1 mm samples underestimated the elastic modulus of the 10.6 mm samples by an average of roughly 20%. Yet no statistical difference was detected between the 8.3 and 10.6 mm samples in either anatomic site, suggesting that 8.3 mm diameter specimens were sufficiently large to avoid side artifacts. FEM models created from micro-CT images reveal that modulus approaches an asymptotic value with increasing diameter, and demonstrate an architecture-dependent drop in modulus at decreasing diameters. These results confirm, both experimentally and numerically, that side effects can be ignored given a suitably large specimen diameter and that this minimum diameter will be dependent on the cancellous architecture. An important implication of the latter result is that specimen diameters must be chosen appropriately when comparing test groups with different architectures (e.g. normal versus osteoporotic) to ensure that the magnitude of side artifacts does not confound the true differences between the groups.     

Prospective control study using fibrin sealants and Harmonic® scalpel in Latissimus Dorsi flap transfer

Background: Latissimus dorsi flap (LD) is used in breast reconstruction procedures, although prolonged donor site drainage is a frequent complication. To decrease this problem, quilting sutures and/or fibrin sealants were proposed, with alternate results. The primary objective of this study was to assess the effectiveness of Tisseel® in association with the Harmonic Synergy® blade system to reduce this complication. Materials and methods: Between 2010–2012, 20 consecutive patients undergoing immediate unilateral breast reconstruction with LD were enrolled in the study (Group A) and matched with 20 patients in which LD was raised with electrocautery (Group B), and 20 patients in which LD was harvested with Harmonic® (Group C). After informed consent acquisition, Harmonic® was used in Group A for LD harvesting, but differed from other groups as fibrin glue was applied to the donor site prior to closure. In all groups donor site drainage measurements at 24 and 48 hours, total drain volume, days to drain removal, operation time, and complication rate were recorded. Pearson’s Chi-squared, ANOVA, and Bonferroni post-hoc tests were used to analyze the data. Results: Data analysis did not show any statistical difference. Prolonged drains output?≥?15 days occurred in one patient of Group A and C, and in three Group B patients. Conclusion: Although the combined use of Harmonic® and Tisseel® presents a low donor site fluid collection rate, the fibrin glue seems not to have further beneficial effects in reducing the post-operative serous drainage or to lead to an early drain removal when compared to Harmonic® only.     

Bone remodelling in humeral arthroplasty: follow-up using CT imaging and finite element modeling – an in vivo case study

Little material is available in the literature about remodelling of the human humerus after implantation of a shoulder hemiarthroplasty. A 73-year-old patient was examined by CT 4 years after implantation of a right shoulder hemiarthroplasty, and the bone density as represented by Hounsfield values was compared with the contralateral side. Additionally, a three-dimensional finite-element model was generated from the image data and analysed. Bone density was reduced around the prosthesis when compared with the contralateral side. The stresses were transmitted through the prosthesis, while low bone stresses were found surrounding the prosthesis. Distally from the prosthesis, high stresses were found. On the control side, a more homogeneous stress distribution was noted. The results could be explained by bone resorption around the prosthesis caused by stress shielding; this hypothesis has to be confirmed by future studies. Received: 15 December 1998     

Complications in immediate breast reconstruction using Strattice™

Introduction

Immediate breast reconstruction (IBR) is becoming increasingly popular. Implant-based IBR has a lot of benefits over autologous IBR but also carries the disadvantages associated with implant use. Acellular dermal matrix, such as Strattice?, has been used as an alternative approach to provide implant coverage.

Methods

All cases of implant-based IBR using Strattice? performed between 2009 and 2011 at the North Tees and Hartlepool Breast Unit were reviewed to assess the outcomes, complications and impact on adjuvant therapy with the use of Strattice? in IBR.

Results

Twenty-one implant-based IBR utilising Strattice? in 17 patients were reviewed, four were bilateral procedures. Ten patients had complications, nine of whom required a clinical intervention for these complications. Four patients had a foreign body reaction associated with a seroma. Five patients had a wound breakdown with eventual loss of the implant and one patient had an early contracture following radiotherapy. Four patients requiring adjuvant radiotherapy had a delay in starting treatment. Three out of six patients requiring adjuvant chemotherapy had a delay in commencing treatment, and three patients experienced delays between cycles resulting from complications.

Conclusions

Strattice? may offer an alternative solution to problems in implant-based reconstruction but there are concerns regarding the development of complications associated with this. Complications may delay adjuvant therapy. Further studies should investigate the impact on adjuvant therapy, when using Strattice? in IBR. Level of evidence: Level IV, therapeutic study.     

Quantification of macrovesicular and microvesicular hepatic steatosis in rats using 3.0-T ¹H-magnetic resonance spectroscopy

Background and objective

Hepatic steatosis (HE), which is common among the general population, is present in donor organs, potentially affecting their graft survival as well as the recovery of the donor. Our goal was to develop an experimentally and clinically reliable, noninvasive method to quantify macrovesicular and microvesicular hepatic steatosis using 3-T ¹H-magnetic resonance spectroscopy (MRS).

Materials and methods

Macrovesicular and microvescular steatosis were induced in rats using methylcholine deficiency and choline deficiency diets. A MayoBC10 coil was used for radiofrequency transmission and signal recept. Measurements of hepatic fat content were performed using ¹H spectroscopy on a 3.0-T whole-body GE Signa system. The ratio of the areas under the curve of fat (0.8-1.3 ppm) and water (4.7 ppm) was used to determine hepatic fat content, which was compared with the degree of histopathologic and biochemical steatosis.

Results

Twenty rats were divided into two groups based on the percentage of microvesicular liver steatosis. Group A (n = 13) was the lower percentage group (microvesicular < 10%) while group B (n = 7), the higher group (microvesicular ≥ 10%). The mean total fatty change in the liver was 58.4% ± 47.2% and 67.6% ± 39.1% in groups A and B, respectively. A highly significant linear correlation between ¹H-MRS and total fatty change was observed in group A (r = .986, P < .001) while there was a relatively poor correlation in group B (r = .764, P = .05). The power to predict fatty change in the liver in groups A and B was significantly different (P = .004).

Conclusions

The degree of hepatic steatosis with a small amount of microvesicular steatosis (<10%) can be precisely predicted using 3-T ¹H-MRS.     

Microstructure of the trabecula and cortex of iliac bone in primary hyperparathyroidism patients determined using histomorphometry and node–strut analysis

The purpose of this study was to use histomorphometry to compare the microstructure of trabecular and cortical bone in patients with primary hyperparathyroidism (PH) with that seen in osteoporosis. Histomorphometric and node–strut analyses of iliac bones were performed on 11 female patients with PH (61.3 ± 8.0 years old) and 61 age-matched female patients with involutional osteoporosis (OP) (63.6 ± 5.6 years old). Cancellous bone volume (BV/TV), trabecular thickness (Tb.Th), trabecular number (Tb.N), trabecular separation (Tb.Sp), and wall thickness (W.Th) were not significantly different in these two groups. The bone formation rate (BFR) tended to be higher in the PH group than in the OP group. The number of nodes (N.Nd/TV) and node-to-node strut length (Nd.Nd/TV) were significantly higher in the PH group than in the OP group. The number of termini (N.Tm/TV) and terminus-to-terminus strut length/total strut length (Tm.Tm/TSL) were significantly lower in the PH group; cortical porosity was significantly higher in the PH group than in the OP group. No correlation was found between age and N.Nd in the PH group, but there was a negative correlation between age and N.Nd in the OP group. Our results show that trabecular connectivity was maintained while cortical porosity deteriorated in patients with PH compared with OP. These results suggest that there are microstructural differences between PH and OP in cancellous and cortical bone that result from the bone remodeling sequence in humans. Received: Nov. 20, 1998 / Accepted: March 12, 1999     

The incidence of postoperative flare reaction and tissue complications in Dupuytren’s disease using tension-free immobilization

Purpose

Open fasciectomy represents a standard treatment of Dupuytren’s disease. Although patients are commonly immobilized in extension to prevent postoperative contracture formation, immobilizing the extremity under tension may precipitate a flare reaction and scar-related complications. This study explores the incidence of flare reaction and other complications with postoperative tension-free splinting after fasciectomy for Dupuytren’s contracture.

Methods

We retrospectively reviewed patients’ charts that consisted of 228 procedures in 191 patients who underwent surgery by the senior author between 2000 and 2010. Postoperative notes were reviewed for wound healing problems, scar appearance, flare reaction, and complications. The grading system defined by Evans et al. was used to standardize flare reaction and scar complications.

Results

Using tension-free splinting, the incidence of flare reaction was 3.5 % (8/228). The eight patients that had flare reactions had mild involvement, and no severe reaction was observed. Fifteen patients had hypertrophic scars, eight had hypersensitive scars, and six had recurrent contractures.

Conclusions

The incidence of flare reaction using tension-free immobilization postoperatively was low in our study. According to our findings, wound healing problems are rare when tensionless splinting is utilized. Type of study/level of evidence Case series, Level IV, Therapeutic study     

The efficacy of combination therapy using adeno-associated virus—interferon β and trichostatin A in vitro and in a murine model of neuroblastoma

Purpose

Trichostatin A (TSA) is a potent histone deacetylase inhibitor and has demonstrated significant antitumor activity against a variety of cancer cell lines. Type I interferons have also shown significant antitumor as well as antiangiogenic activity. In this study, we examined the effectiveness of combination therapy of TSA and interferon β (IFN-β) on human neuroblastoma cells in vitro and in vivo using a murine model of retroperitoneal neuroblastoma.

Materials and Methods

For in vitro experiments, plated human neuroblastoma cells (NB-1643 and NB-1691) were treated with vehicle or with IFN-β, TSA, or both for 24 hours. Cytotoxicity was assessed by counting cells and expressing the results as a percentage of controls. Expression of the tumor suppressor p21^Waf1 was assessed by Western blot. For in vivo experiments, retroperitoneal neuroblastomas were established in severe combined immune deficiency (SCID) mice. Interferon β was given using a gene therapy approach, administering 1.5 × 10¹⁰ particles of an adeno-associated virus vector encoding human IFN-β (AAV hIFN-β) via tail vein as a single dose per mouse. Trichostatin A was given at a dose of 5 mg/kg every 48 hours subcutaneously. Treatment groups included controls, AAV hIFN-β alone, TSA alone, and AAV hIFN-β together with TSA. Tumor volume was assessed 2 weeks after the treatment began.

Results

After 24 hours, treatment with IFN-β, TSA, and a combination of both resulted in a 45.3%, 68.1%, and 75% reduction in cell count relative to controls in the NB-1691 cell line. In the NB-1643 line, cell counts were reduced by 23%, 58%, and 62.3% respectively. In addition, NB-1691 cells treated with TSA showed increased expression of p21^Waf1 on Western blot. For in vivo experiments, control-, AAV hIFN-β-, TSA-, and combination-treated tumors had the following final volumes: 1577.7 ± 264.2 mm³ (n = 3); 128.5 ± 74.4 mm³ (n = 4; P = .0001); 1248.7 ± 673.9 mm³ (n = 4; P = .48); and 127.5 ± 36.8 mm³ (n = 4; P = .0007), respectively.

Conclusion

Neuroblastoma, because of its unique biology, continues to be a challenging tumor to treat, and many times these tumors are refractory to standard chemotherapeutic regimens. These data show that both TSA and IFN-β inhibit neuroblastoma growth and that the combination may potentially provide a unique way to treat this difficult disease.     

Porcine wound healing in full-thickness skin defects using Integra? with and without fibrin glue with keratinocytes

BACKGROUND:

An artificial dermal matrix such as Integra (Integra Life Sciences Corporation, USA) provides a wound bed template for vascular and fibrocyte ingrowth as well as collagen remodelling. Dermal repair leads to epidermal and basement membrane regeneration. Burn wounds in particular have been shown to benefit from Integra by enhanced wound healing.

OBJECTIVE:

To evaluate the effect of fibrin glue to modify the integration of Integra in large excised cutaneous wounds. It was hypothesized that applying fibrin glue on a wound bed would reduce the time needed for matrix vascularization and incorporation of Integra and take of the cultured keratinocytes.

METHODS:

Four separate full-thickness wounds were created on the dorsum of two swine. Wound beds were randomly assigned to either application of fibrin glue or no application of fibrin glue before application of Integra. Full-thickness biopsies were performed at days 7, 14, 21, 29 and 35. On day 21, keratinocytes were applied either as sheets or aerosolized fibrin glue suspension.

RESULTS:

Histological analysis revealed a wave of inflammatory cells and early granulation tissue ingrowth into the Integra from the fascia below on day 7. Only this initial phase was augmented by application of fibrin glue to the wound bed. By day 14, most and by day 21, all of the Integra thickness was incorporated. Accelerated dermal repair proceeded from the base with new collagen deposition in Integra spaces. There was no evidence of keratinocyte engraftment, although re-epithelialization occurred at wound edges extending onto the incorporated Integra.

CONCLUSIONS:

It appears there is an acceleration of early phase (day 7 to day 21) dermal incorporation with fibrin glue application to the wound bed, perhaps secondary to increased cellular migration. Day 21 appears to be too early to apply cultured keratinocytes either as sheets or aerosolized suspension.     

Serum levels of megestrol acetate，reproductive hormones and morphological changes in women using megestrol acetate silicone r

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Can intracellular Staphylococcus aureus in osteomyelitis be treated using current antibiotics? A systematic review and narrative synthesis

Approximately 40% of treatments of chronic and recurrent osteomyelitis fail in part due to bacterial persistence. Staphylococcus aureus, the predominant pathogen in human osteomyelitis, is known to persist by phenotypic adaptation as small-colony variants(SCVs) and by formation of intracellular reservoirs, including those in major bone cell types, reducing susceptibility to antibiotics.Intracellular infections with S. aureus are difficult to treat; however, there are no evidence-based clinical g...     

Clinical and radiological outcomes using the LIMA SMR stemless implant—A 2-year follow-up in 49 patients

BackgroundSince the introduction of stemless anatomic total shoulder arthroplasty (TSA), many studies have been published on this specific group of TSA implants. The following study aimed to evaluate clinical and radiological short- to mid-term outcomes of the LIMA SMR stemless anatomical implant.MethodsWe prospectively evaluated the outcome of 53 TSAs in 52 patients, with a mean age of 58.45 years (range 47-78 years) at the time of implantation with a minimum follow-up of 2 years (range 24-47 months). All patients were physically and radiologically examined; the results were documented by the Constant-Murley Score and the Simple Shoulder Value.ResultsSignificant improvements from preoperative to latest follow-up were documented in Constant-Murley Score (29.0-75.84 pts; P < .001), active range of motion (abduction 84.7°-133.2°, flexion 95.3°-146.4°, and external rotation 12.7°-32.4°). The mean Simple Shoulder Value was 82.15% at the last follow-up. There was no complete loosening of the humeral component, but a lowering of bone mineral density (radiolucencies, RLL) was observed in anteroposterior or axially views—radiographs at the humeral component in 10.2% of the cases, most of them on the anteroposterior view at the calcar region. There was no statistical difference in the outcome of the patients with RLL compared with the ones without radiolucencies. Major complications or revisions did not occur.ConclusionThis study provides comparable improvement in functional, radiographic, and subjective mid-term results with other stemless anatomic implants.     

Does bladder tone influence sensation of filling and electro-sensation in the bladder? A blind controlled study in young healthy volunteers using bethanechol

PURPOSE: The influence of bladder tone on filling sensation and electro-sensation in the bladder was studied in young healthy volunteers. MATERIALS AND METHODS: A total of 22 healthy volunteers 18 to 30 years old were included in our study, of whom 15 received a subcutaneous injection of 5 mg bethanechol and 7 received a subcutaneous injection of water to serve as randomly selected controls. In each group filling perception was evaluated during medium fill cystometry before and 25 minutes after injection. The bladder electrical threshold was determined in each group by constant current stimulation before and 25 minutes after injection. RESULTS: In the study group there was a marked decrease in the volume at which various filling sensations occurred after bethanechol was given. The pressure at which all filling sensations were perceived was higher after bethanechol than at baseline cystometry. The electrical threshold decreased with bethanechol. In the control group no change was noted in the perception of filling or electro-sensation. CONCLUSIONS: Bethanechol has a distinct influence on the filling sensation and on electrical bladder stimulation. Each sensation is sharpened after the administration of bethanechol. Several hypotheses are possible to explain these effects.     

Case review: management of life-threatening sepsis and wound healing in a Klippel-Trenaunay patient using serial surgical débridements and vacuum-assisted closure

In Klippel-Trenaunay syndrome surgery is reserved for conditions which result in hemodynamic instability and sepsis. We report a pediatric patient with Klippel-Trenaunay syndrome and life-threatening wound sepsis responding to serial surgical débridements and application of the Vacuum-Assisted Closure device. The device was found to be an effective adjunct to the treatment algorithm.